New Client Letter and Questionnaire

Date*

Name*

First Last

What do you like to be called?*

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Other Phone

Email*

Website*

How do you prefer to be contacted?*

Profession*

Current Employer*

Position*

Relationship Status*

Wedding/Special Anniversary Date (if applicable)

Name of Significant Other (if applicable)

Significant Other’s Date of Birth (if applicable)

Name(s) and Age(s) of Child(ren) (if applicable)

The issue of confidentiality is paramount to this relationship. My understanding is that nothing in this relationship is to be discussed outside of our conversations. There are times when references to others may be helpful, however I would not ever mention a name or person that would lead someone to infer the discussion was about you as a client. I understand that Shoshanna Hecht is not a licensed therapist and that I am responsible for all my decisions, actions and feelings.

Client Signature*

Date*

Client Questionnaire

About Coaching You

1) What are your Top 3 Priorities for our work together?*

2) What specific expectations do you have of me as your coach?*

3) How will you know you are receiving value from this coaching relationship?*

4) If you trusted me enough as your coach to tell me how to manage you most effectively, what tips would you give me?*

About Your Life

1) What accomplishments do you think must occur during your lifetime so that you will consider your life to have been satisfying and well lived -- a life of few or no regrets?*

2) What are the times in your life when you were most fulfilled and alive?*

3) What accomplishments are you most proud of in your life and why?*

4) What’s missing in your life? What would make your life more fulfilling and how do you know that?*

5) What 2 steps could you take immediately that would make the biggest difference in your current situation?*

6) What do you feel people don’t notice about you but wish they did?*

7) What activities bring you joy?*

8) What drives you crazy?*

9) What is a compliment or acknowledgement you hear most often about yourself?*

10) What are your spiritual beliefs? Do you believe in the concept of a higher power? Please describe the most useful, empowering aspects of your spiritual beliefs.*

11) Are you currently or have you ever been in therapy?*

12) What else would you like me to know about you?*

Wheel of Life

Imagine that this wheel represents your life. Starting with “Health,” indicate how satisfied you are at this moment by coloring in a number from 1-10 (1 is least, 10 is most).

Now repeat this step for the remaining seven categories.

Career*

Money*

Health*

Friends and Family*

Significant Other*

Personal Growth and Learning*

Fun, Leisure and Recreation*

Physical Environment (eg. Home)*

Start Flexing Your 'No' Muscle Today

Welcome

Client Questionnaire

Wheel of Life

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